How to apply and pay Independence Blue Cross (IBC) makes applying and paying for dental and vision coverage easy by providing you with several options that suit your needs. Application options 1. Apply online If you prefer to apply online, please visit ibx4you.com/dentalvision to complete the online application and payment information forms. 2. Apply by phone If you would like to speak with a licensed sales representative, please call 1-844-762-2140. 3. Apply by mail Apply online www.totalbenefits.net ibx4you.com/dentalvision Enclosed you’ll find an Application for Adult Dental and/or Vision Individual Coverage and postage-paid return envelope, which you can fill out and mail in along with your initial payment. Initial payment options IBC offers various options for paying your monthly premium. You can choose to make your first monthly payment by check or credit/debit card, or you can sign up for an automated monthly payment from your bank account through Automated Clearing House (ACH). Please be aware that since dental and vision coverage are provided through separate contracts, they will be invoiced and billed separately. The payment information provided will be applied to the premiums of the dental and/or vision coverage selected. Check Apply by phone 1-844-762-2140 If you’ve selected monthly billing on your application, you will need to include a check with your first payment. Please make your check payable to Independence Blue Cross. Once you’re enrolled in a plan, you will receive a bill each month before your payment is due. Credit/Debit card __________ __________ __________ __________ Apply by mail with the prepaid return envelope. If you choose to use a credit/debit card, please follow the instructions on this form and return it with your application. Please note that we accept Visa or MasterCard for credit/debit card payments, and that credit/debit card is only accepted for the first month’s premium. Initial payment — credit card Cardholder name:______________________________________________________ Credit card type: Visa MasterCard Credit card number:_____________________________________________________ Security code: ____________________________ Expiration date:_______________ This three-digit security code can be found on the back of your card. Cardholder’s billing address:______________________________________________ ______________________________________________ City, State, ZIP: ______________________________________________ For more information contact your independent broker Total Benefit Solutions Inc (215)355-2121 http://www.totalbenefits.net Ongoing payments Monthly Payments by Check If you have selected monthly billing on your application, you will receive a bill each month before your payment is due. You will need to include a check with your monthly payments. Please make your check payable to Independence Blue Cross. Automated Clearing House (ACH)/Electronic Check Questions? Please call: 1-844-762-2140 Independence Blue Cross offers a free electronic monthly premium payment service. You authorize the withdrawal of your total premium amount due from your checking or savings account, and IBC will deduct your payment through the ACH process. With the electronic monthly premium payment service, there’s no need to wait for your invoice to come or mail payments each month. Payment is automatic and always on time. Important instructions: 1. Complete and sign this form. 2. Attach a voided check (for checking accounts) or deposit slip (for savings accounts). 3. Return this form with your application in the postage-paid reply envelope provided. Note: Your payment will not be processed until your coverage is approved. Name of account holder:___________________________________________________ Bank routing/transfer number:______________________________________________ Bank name 9-digit routing number Your account number Relationship to applicant:__________________________________________________ Bank account number:_____________________________________________________ Name of financial institution:_______________________________________________ Type of account: Checking Statement savings (No passbook accounts) Bank account usage: Personal Business Account holder signature: ____________________________________________ Date:__________ Additional signature (if joint account): _________________________________ Date:__________ Signature of applicant: ______________________________________________ Date:__________ (if different than account holder) I (we) authorize my bank or savings institution to make payments to Independence Blue Cross from the account listed above. I (we) understand this authorization may be revoked by me at any time, by written notification, to discontinue my automatic payment. I (we) agree to maintain sufficient funds in the account to permit these deductions. If the account does not maintain sufficient funds, electronic payments will be cancelled and I (we) will be billed through the postal service (regular mail). All plan termination notices should be sent to: Independence Blue Cross, Billing Department, P.O. Box 13828, Philadelphia, PA 19101-3828. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. For more information contact your independent broker Total Benefit Solutions Inc 17527 2013-1242 (2/14) (215)355-2121 http://www.totalbenefits.net